Health Departments in Georgia: A Mixed Methods Approach Y ou may - - PowerPoint PPT Presentation

Quality, Cost and Value of Public Health Services Thursday, May 21, 2015 1:00 - 2:00 pm ET

Exploring Cost and Delivery of STI Services by Health Departments in Georgia: A Mixed Methods Approach

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PHSSR NATIONAL COORDINATING CENTER AT THE UNIVERSITY OF KENTUCKY COLLEGE OF PUBLIC HEALTH

PHSSR Research-In-Progress Series:

Agenda

Welcome: C.B. Mamaril, PhD, Research Assistant Professor, Health

Management & Policy, University of Kentucky College of Public Health

“Exploring Cost and Delivery of STI Services by Health Departments in Georgia: A Mixed Methods Approach” Presenters: Gulzar H. Shah, PhD, MStat, MS gshah@georgiasouthern.edu and

Angie Peden, MPH apeden@georgiasouthern.edu Georgia Public Health PBRN, Jiann-Ping Hsu College of Public Health, Georgia Southern University

Commentary: William Livingood, PhD, University of Florida College of

Medicine-Jacksonville William.Livingood@jax.ufl.edu Saroyi Morris, MHS, DrPH(c), District Program Manager, Coastal Health District, Georgia Department of Public Health Saroyi.Morris@dph.ga.gov

Questions and Discussion

Presenters

Gulzar H. Shah, PhD, MStat, MS

Associate Professor & Associate Dean for Research gshah@georgiasouthern.edu

Angie Peden, MPH

Coordinator, Office of Public Health Practice Center for Public Health Practice and Research apeden@georgiasouthern.edu

Georgia Public Health PBRN Jiann-Ping Hsu College of Public Health, Georgia Southern University

Cost of STI Services in Georgia: A Mixed Methods Approach

Gulzar H. Shah, PhD, MStat, MS

Associate Dean for Research and Associate Professor Jiann-Ping Hsu College of Public Health

Angie Peden, MPH

Coordinator, Office of Public Health Practice and GA Public Health PBRN Jiann-Ping Hsu College of Public Health

Outline

• Background
• Purpose
• Methodology
• Findings
• Q&A

Shah 5

Background

• Georgia has some of the highest national rates
• f Gonorrhea, Chlamydia and Syphilis.

– Georgia ranks 6th in gonorrheal infections – 13th in chlamydial infections – 3rd in primary and secondary syphilis infections (CDC, 2010) – Georgia’s overall STD rate was 703.9 (per 100,000) (OASIS, 2011)

Shah 6

Background

• STIs continue to be a major local public health

delivery issue.

• Variation in cost of STIs across the country.
• Research elsewhere shows that there might

be ways to reduce the cost.

Shah 7

Background

Shah 8

Purpose

• To explore ways to estimate the costs of

delivering public health services based on qualitative information from each of the eight counties in a GA Health District’s (HD) jurisdiction, comprising both urban and rural counties.

– A sub-aim is to identify and validate appropriate cost components for the STI program, and sources

• f data for cost component.

Shah 9

Purpose (2)

• Examine variation in delivery system

characteristics including:

– centralization of IT and HR systems, – responsiveness to local community governance.

Shah 10

Purpose (3)

• Allow comparative analyses and contrast findings from

Georgia and Florida studies: – Compare each state’s local public health delivery system characteristics.

• The Georgia-Florida comparison for centralization

versus decentralization of service provision and information systems will have much broader policy and practice implications.

Shah 11

Methodology: Qualitative

• Interview Guide Developed by Research Team

– Guide included 9 open-ended interview questions with specific probes

• Key Informants identified by District

Leadership.

– Included: County Nurse Managers (8), Site Nurse Supervisors (2), District Administrators (2), and the District Nursing Director, STI Director, Women’s Health Coordinator, and Ryan White Director.

Shah 12

Methodology: Qualitative

• Research Team conducted 16 interviews

ranging from 30 – 60 minutes.

– Semi-structured interviews were recorded, transcribed, verified. – Data were coded and analyzed using NVivo. – Interviews were iteratively coded and recoded to maximize inter-coder consistency

Shah 13

Methodology: Quantitative

• Study population: all 159 counties served as the study

population.

• Used census design

– All counties were contacted to identify the county staff with specialized knowledge regarding administrative and clinical protocols.

• A structured survey instrument was developed

– adapted questions from Florida PBRN cost study.

• The modified survey was pilot tested by select District STD/CDS

Managers.

• The final survey was distributed to:

– District STD/CDS Manager – District CDSs – County Nurse Managers

Shah 14

Methodology: Quantitative

• Qualtrics survey software was used to

distribute the survey.

• 2 follow-ups via emails were sent.
• 195 surveys were distributed.

– 177 were partially or completely answered – Response rate of 90.8% – Responses represented 157 of Georgia’s 159 counties. – 134 complete responses included in the analysis

Shah 15

Methodology: Quantitative

• Used SPSS 22 for data cleaning and analyses
• Descriptive analyses performed for the main

report

Shah 16

Shah 17

Qualitative Findings

• Ten major themes emerged from the key informant

interviews:

– STI Services – STI Services by County and District Staff – Individuals Who Provides STI Screening – Referral of STI Services by Non-Public Health Agency and Health Care System – Monitor and Report of STI Services – Costs Related to STI Services – Data Collection and Report for Delivering STI Services – Data Quality and Completeness – Administrative Differences in Providing STI Services – Future Study Approaches for Cost Estimation of STI Services

Shah 18

STI Services

• Organization of STI services both in urban and rural areas in

the health district and counties.

– Most common STI services:

• Screening and testing
• Outreach and education
• Treatment
• Partner notification

– Least common STI services:

• Patient counseling
• Physical exam
• Providing information and education at health fairs
• Lab testing

Shah 19

STI Services by County and District Staff

• STI services for syphilis, chlamydia, and gonorrhea were

provided by the county health departments utilizing local Board of Health staff.

• STI services such as outreach, screening, education, and

partner notification were provided by both county and district staff, and in-house screening and treatment were done by the county staff.

“…if we're doing an educational service, we may have county staff and district staff working hand in hand”

Shah 20

Individuals Who Provides STI Screening

• STI screening was most commonly provided by county health

department nurses.

• Communicable Disease Specialists (CDSs) at some county

health departments provided other STI services such as

• utreach and community education, pre- and post-test

counseling, and partner notification.

Shah 21

Referral of STI Services by Non-Public Health Agency and Health Care System

• STI services provided to people who were referred by non-public

health care systems:

• emergency rooms,
• primary care provider, and
• Federally Qualified Health Centers (FQHCs)

– An estimated 10 percent of all services resulted from referrals by non-public health care systems.

“…we do have a good working relationship with all of our…partners…if it’s something that they do not provide…like so many people may not have a job and they may not have insurance and it’s something we can do within the Board of Health…”

Shah 22

Process/Systems for Monitoring/Reporting STIs

• STI services were monitored and reported electronically by

the county health department.

– Used Mitchell & McCormick Visual Health Net (VHN) systems and State Electronic Notifiable Disease Surveillance System (SendSS). “We monitor – the positives…to be reported to our district communicable disease specialist and…to the state of – he enters into Sendss… and – because the tracking of Gonorrhea and Chlamydia is very important and

• Syphilis. He enters that into the Sendss system for the state…”
• In many cases, STI records are maintained and reported both

at the county level by nurses and district level by CDSs or a collaboration of the two.

Shah 23

Costs Related to STI Services

• Fixed Cost Components
• 1. Staff (i.e., nurses and clerical)
• 2. Labs for testing chlamydia, gonorrhea, and rapid plasma

reagin (RPR)

“labs are usually fixed for one year at a time and then we…either continue with the same lab company that we used or that can change”

• 3. Examination

“the actual STD examination where patient comes in…to be seen by a nurse or practitioner to get a physical exam and history, we charge 40 dollars”

Shah 24

Costs Related to STI Services

• Variable Cost Components

– Staff (i.e., salaries and fringes) – Medical supplies (i.e., speculums, needles, exam paper, gowns, and gloves) – Postage to mail notifications “our highest [variable] cost is postage, because we have to mail out three letters and one has to be certified...” – Travel to patients’ residence – Phones calls to contact patients – Printing for outreach – Partner notifications “If he has one partner that’s a 15 minute interview probably. But if he comes in and…got 10 partners that may be [a] 30 to 45 minute interview.”

Shah 25

Data Collection and Report for Delivering STI Services

• A common method to track financial reporting mechanisms for the cost

components was staff completing a task survey every quarter to capture their duties and time in an eight-hour period in 15 minutes increments.

• Type of Data Collected

– Cost of STI services and testing – Number of patients with a specific STI – Demographics and location of patients with STIs – Number of STIs seen per month in the health department – Number of STI patients seen by the nurse – Cost paid or not paid by each patient

Shah 26

Data Collection and Report for Delivering STI Services

• Individuals responsible for collecting and recording data included county

nurse managers, CDSs, district staff, accounting department, clerks, and program directors.

• Time period these data are available is daily, weekly, monthly, and

quarterly.

Shah 27

Administrative Differences in Providing STI Services

• Few county and district staff were aware of administrative

differences in providing STI services across health districts and counties in Georgia.

– Rural counties

• Not accepting walk-ins due to lack of staff

“These smaller counties,…might only have one nurse because another nurse is out at a meeting or,…on a conference call.” So if someone walked in our door right now they either have to wait a …good while or be scheduled to come back the next day. Because…we don’t have the volume

• f nurses or CDS workers that the larger counties have.”

– Urban counties

• Fee schedules (i.e., $50 walk-in fee)
• More grants/funding and CDSs

Shah 28

Shah 29

Percent Distribution of Responses by Title (n=134)

Shah 30

108 19 4 3 20 40 60 80 100 120 County Nurse Manager District STD/CDS Manager Other Communicable Disease Specialist (CDS) Number of participants Title of the survey participant

Percent Distribution of Location of STD Screening

Shah 31

100% 5.20% 21% 0% 20% 40% 60% 80% 100% 120% County Health Department Clinic Outreach Other Percent Location of STD Screening

Percent of clients screened for diagnosis of Gonorrhea/Chlamydia in health departments’ clinics

Shah 32

Urine Aptima Provider collected swab (Aptima) Self-collected swab (Aptima) Culture

9.0% 15.7% 16.4% 24.0% 15.7% 19.4% 0.0% 10.0% 20.0% 30.0% Percent of counties Percent of clients screened using this … 1.5% 14.2% 14.9% 19.4% 20.9% 29.1% 0.0% 10.0% 20.0% 30.0% 40.0% Percent of counties Percent of clients screened using this … 0.0% 0.0% 0.0% 0.7% 1.5% 97.8% 0.0% 50.0% 100.0% 150.0% Percent of counties Percent of clients screened using this … 1.5% 1.5% 0.0% 1.5% 2.2% 93.3% 0.5 1 Percent of counties Percent of clients screened using this …

Average percent of type of staff that usually performs STD investigations

Shah 33

County Health Department (CHD) staff 45% District Health Department staff 54% Other 1%

Mean and Median Estimate of the Time it Takes to do Treatment Verification

Shah 34

Source N Mean (time in minutes)

• Std. Deviation

Median (time in minutes) Private Physicians 86 267.22 971.770 30.0 Emergency Departments 78 181.74 750.533 30.0 Hospitals 75 282.31 1144.848 30.0

Parameters for Partner Notification

Shah 35

38% 29.90% 15.70% 11.90% 4.50% 0% 5% 10% 15% 20% 25% 30% 35% 40% All clients diagnosed through CHD clinics or CHD

• utreach services

No Response All positive STI results in county Only STI positives prioritized for partner notification Other P e r c e n t Parameters for partner notification

Priority Populations

Shah 36

7% 10% 8% 0% 2% 4% 6% 8% 10% 12% Migrant Workers Sex Workers High Risk Zip Code Percent Populations

Services for Partner Notification

Shah 37

37% 40% 59% 0% 10% 20% 30% 40% 50% 60% 70% Identification Outreach/Initial Contact Counseling/Risk Education Percent Services

STD Clients with Insurance Coverage (including Medicaid, Medicare, Private) insurance)

Shah 38

7% 4% 13% 0% 2% 4% 6% 8% 10% 12% 14% 16% 76-100% 51-75% 26-50% Percent Services

Contact Info:

Gulzar, gshah@georgiasouthern.edu or 912-478-2419 Angie, apeden@georgiasouthern.edu or 912-478-2581

Commentary Questions and Discussion

William Livingood, PhD

Senior Research Scientist, University of Florida College of Medicine-Jacksonville Center for Health Equity and Quality Research

William.Livingood@jax.ufl.edu

Saroyi Morris, MHS, DrPH(c)

District Program Manager, Coastal Health District Georgia Department of Public Health

Saroyi.Morris@dph.ga.gov

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